Difficulty getting tested for BIA-ALCL, WHY?

Question

Why are Plastic Surgeons reluctant to test for BIA-ALCL in symptomatic women? Women with spontaneous breast swelling, capsular contracture, swollen lymph nodes - all reasonable symptoms that should trigger a PS to test for BIA-ALCL. Thank you

Lu-Jean Feng, MD · Answer

Our pathologists screen for any and all abnormalities, looking for any microorganisms to include bacteria, yeast, and fungus as well as all cancers. Based upon their findings further tests will be conducted such as specific staining to test for cancer like CD30, culture and sensitivities, etc. As pertains to ALCL, it is standard practice for our pathologists to look for abnormal lymphocytes within the capsule. When abnormal lymphocytes are present, they will continue testing for the CD30 marker using immunofluorescent staining on samples taken from the capsule tissue. The CD30 positive cells that are in abnormal groupings or have abnormal morphology (shape and features) are indicative of ALCL. Flow cytometry can only be done on fluid, if fluid is found around the capsule this test may be performed. The costs for additional testing for ALCL can range from $700-$1900, and may not be covered by insurance particularly if it is not indicated by initial pathology findings. The recognized treatment for ALCL, according to the National Comprehensive Cancer Network, is removal of the implants and total capsulectomy (removal of the capsule). I hope this helps.

Joseph L. Grzeskiewicz, MD, FACS · Answer

I can't tell for sure if you are asking a question or making more of a comment about plastic surgeons and the management of ALCL in general, but it is a very pertinent subject right now, so I would like to address it.  First, I don't think that one can make the generalization that plastic surgeons are reluctant to test for BIA-ALCL in "symptomatic women."  I don't agree with that remark.  It could be that some are for some reason, but in such cases it may be just that they are not yet familiar with this very rare and little understood condition.  There has been plenty of information disseminated through the professional plastic surgery societies over the past year or so on this subject, though, and those surgeons who are up to date on the latest studies and literature related to this condition will most likely be very vigilant with testing for this.  The problem with this condition is that we in the plastic surgery community are just now starting to understand the best ways to diagnose and treat it.  Because it is extremely rare, and the data that have been collected on the condition thus far are either incomplete or in some cases inaccurate, we are having some difficulty knowing exactly how to proceed at the moment.  On the one hand, I don't believe any doctor wants to standby and see any patient subjected to a risk of cancer, nor do we want to simply put profit motives over our concern for our patients' health and well-being just so we can do more surgery.  On the other hand, I don't think we want to create a lot of needless hysteria without sound scientific evidence for our recommendations, thereby "throwing the baby out with the bathwater" and abandonning a very beneficial treatment option for many ladies because of unfounded fears without scientific support.  At present, there seems to be a preponderance of the BIA-ALCL cases associated with very specific types of implants, so to be concerned about all implants at this time would be sort of like saying "this particular model of car has a problem with its gas tank, so we're going to take all cars off the road."   This is our dilemma right now with regard to ALCL associated with breast implants.As far as the specific types of cases you cite and your specific comment, whether it's you or someone else you're talking about, clearly if a lady presents with a problem or symptom like late onset swelling in the breast, new mass, pain, enlarged lymph nodes, or anything else out of the ordinary, based upon what we already do know, in my opinion, it is incumbent upon any evaluating plastic surgeon to properly assess the symptoms and findings, and if they suggest the presence of ALCL, they MUST be tested for.  This includes obtaining any fluid around the implant for cytology and cell marker studies, such as CD30 and ALK, and/or obtaining any availabe tissue specimens to be sent for analysis.  We should remember, however, that not everything that we see in a breast postoperatively is ALCL, and that includes routine capsule contracture, for in the vast, vast majority of cases, it is simply garden variety capsule contracture or some other routine issue and not ALCL.  BIA-ALCL happens roughly 1 in a million times with breast augmentation, so that is pretty rare.  As I said above, we're still trying to figure out the best ways to diagnose and manage this condition, but it has to be kept in perspective too.I hope this addresses your concerns and provides some clarity on where we stand as plastic surgeons with regard to ALCL at the moment.  If you or anyone you know has breast implants in place and is concerned about a recent change in one or both breasts, or has concern about the presence of ALCL, she should contact a board certified plastic surgeon, preferably one with knowledge about the issue of ALCL and experience with breast implant surgery (most surgeons will never have actually seen a case of ALCL in their careers, though), so that she can be properly evaluated.

Edward J. Domanskis, MD (in memoriam) · Answer

Most definitely BIA-ALCL should be tested for with CD 30 test of any fluid that is present around an implant or any tissue that is removed from a patient that has or had breast implants whether it was textured or not.

Difficulty getting tested for BIA-ALCL, WHY?

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Difficulty getting tested for BIA-ALCL, WHY?

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